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Can PBC restore nurses' confidence?

Marilyn Eveleigh
Consultant Editor

In order to deliver high-quality, caring, holistic services, the staff working within healthcare organisations need to feel confident and valued for what they do. Patients accessing health services exhibit high levels of anxiety with a loss of control and personal autonomy. As we enter 2007, many staff in NHS organisations seem to exhibit these same symptoms - and this is particularly so for nurses. Morale is low.
Why is this? National data indicates an NHS in financial crisis; we are in the middle of yet another reorganisation; there are increased workloads and responsibilities; and we have an aging nursing workforce disappointed by pay levels. Local solutions have included staff giving up holiday, working one day unpaid, not filling vacant posts, and most sadly, nursing redundancies.

Workforce uncertainty
I have mixed impressions on why reducing the nursing workforce is necessary. This includes Payment By Results (PBR), where patient education and self-management is not in the tariff price. Improved equipment and training means that nursing responsibilities can be transferred to healthcare assistants - as in community insulin management. Then there is the high cost of specialist and consultant nursing roles that have difficulty proving their value in a severely overspent trust. The shift of services from hospitals to the community has been hampered by the lack of community facilities and mindset to make it happen, hence redundancies. PCTs are amalgamating and reorganising, with a consequent loss of staff, and new independent providers who might employ nursing staff are not in abundance at the present time. Finally, there are mutterings that in a business culture, there is a perverse incentive to empower patients (as nurses do) when your income is secured, through admissions or episodes of care.
All of the above reasons may not be true or valid, but the collective impact of potential redundancies on a workforce is huge. Careers, loyalties and sacrifices made by individuals can be swept away by a short- term "change in management focus or commissioning decision". Being told that your role and service is no longer wanted/necessary/cost-effective invalidates the person and their past responsibilities unless handled extremely sensitively. And sensitivity is often in short supply when organisations are undergoing change and uncertainty.  

Practice-based commissioning to the rescue
Interestingly, it feels to me that primary care is relatively stable at the moment. Maybe the economic concerns of a new GMS contract have been allayed now that GPs have had a 30% increase in income? GPs are realising the power they hold over deciding the services and providers they want for their patients. But have primary and community nurses grasped the influence they have over future patient services, many which could be nurse-led? Better still, have they got a place at practice-based commissioning (PBC) meetings where they can make a difference?
Remember, PBC will determine the shift of services - and funds - from secondary to primary care. It will be in place by April 2007 and will include elective operations, outpatients, community nursing, diagnostics and mental health. Nurses must be involved in PBC to ensure that NHS changes provide a smooth transition of care for patients. We work with, and depend on, many of the specialist nursing services that are presently being shifted or disbanded. Their function is still fundamental to quality patient care - and, yes, it needs to be in a community setting. They may need to work differently but they are needed. So say so - through PBC! 

Are you up for it?
Primary care is being charged with determining future healthcare - and despite QOF, there is relative stability in the function and achievements of general practice. PBC can harness the collective judgment and strength of nursing to bring stability and confidence back to the wider nursing workforce - and to patients. Are you up for the PBC challenge in 2007?